Dental therapist and reader panel member Cat Edney discusses full scope team working.
Working with a hygienist or therapist in practice has become a widely adopted strategy across the UK, however, how that works for each practice can also vary widely. It is often reliant on the experience of the hiring practice and team within to be able to understand not only the scope of hygienists and therapists but also how to integrate their skills into practice.
There are a number of ways of integrating hygienists and therapists into regular treatment modalities within practice; it is important that the practice finds the model that suits them, and the team. Having a great therapist on board can really build and sustain a business due to the extra patient contact you can work with.
The addition of further skills and flexibility around the hygienist and therapist scope of practice has seen this role transform into one that can become the supporting foundation of a well-run business. The following models set out some ways of working, from the traditional scale and polish diary to the well-integrated and fully utilised dental therapist.
Scale and polish only
Predominantly works with NHS
Relies on GDP to provide more in-depth treatment and referrals
Limits treatment success due to time constraints and staff/patient understanding of hygiene treatment.
This predominantly outdated model hails from a time before hygienists had extended duties and responsibilities.
When considering periodontal treatment the onus was solely on the dentist to provide complex periodontal treatment and trends in litigation are beginning to demonstrate that often the treatment was limited or seen as secondary to treatment of the hard tissue dentition.
“Having a great dental therapist on board can really build and sustain a business due to the extra patient contact you can work with.”
Practices still working to this model are sometimes stuck in a loop of seeing patients with longstanding periodontal inflammation not treated in accordance with the British Society of Periodontology (BSP) guidelines - often as the hygiene diaries are full to bursting with short appointments and little scope to expand. Conversely some are empty with a lack of interest in seeing the hygienist due to lack of support from the rest of the team.
The fix to this issue is to rethink the hygienist appointment types, to introduce a periodontal protocol which involves the GDP focusing on educating the patient, and planning comprehensive treatment with the hygienist. This may mean blocking out sections of the hygiene diary in order to make space for these sessions. In the long run these patients continue with their regular hygiene maintenance but with healthier, more treatable mouths and longer lasting dentitions.
Full scope hygiene - GDP referral based
Gives freedom to follow a protocol for treating perio - better outcomes overall with emphasis on patient education from all team members
Allows for further treatment planning on hygienist prescription
Brings further revenue in the form of fluoride applications, fissure sealants, suture removal and restoration adjustments
Additional digital scanning opportunity can be a cost effective way of promoting patient education and discussing cosmetic treatments
Hygiene diary is more flexible and will free up time in the GDP diary by removing small treatments from the GDP.
Most progressive dental hygienists are working toward the above model whereby they are able to work to their full scope. The periodontal treatment planning is carried out by either the hygienist or the GDP; the hygienist is also able to maximise their daily profit by providing additional treatments such as fissure sealants or tooth whitening.
The GDP diary has no reflection of a change - but the patients are accessing comprehensive evidence based periodontal treatment and additional treatments are available with the hygienist such as whitening and fissure seals. This reduces surgery time spent on these treatments for the GDP and allows for more free space in the GDP diary for more profitable, complex treatment.
Hygienists can also be equipped with digital scanners in order to record patients' dentitions, help to monitor soft tissue movements and tooth wear and also promote the conversation around orthodontic work, replacing worn or leaking fillings and educate patients on their dental health.
Full scope therapy -under GDP referral
As full scope hygiene but with additional scope of therapists
Frees up GDP diary for large restorations, extractions, crowns and dentures
Can work well in NHS practice if all Band II is referred to therapist.
Often seen more in the North of England, the therapist is slowly but surely becoming more popular in primary care dental settings. Traditionally therapists were only permitted to work in hospital settings but as legislation changed in 2002, therapists were allowed to work to the prescription of a dentist in practice. The situation improved further when in 2013 direct access was approved for dental therapists and dental hygienists.
By adding the services of a full scope therapist to the dental practice, you free up time for the GDP to concentrate on the larger and more complex restorative cases. This works especially well with GDPs who have further training in implant placement, or have a special interest in complex restorative cases. The therapist is on hand to provide the Class I-V restorations, whitening, impressions and periodontal treatment; they can also be utilised when treatment planning complex cases, taking impressions once the periodontal condition is stable, and generally condensing the GDP diary into check-ups and complex treatments only. The therapist has time with the patient to reinforce what the dentist has suggested and talk through any concerns or different questions the patient has. The therapist may also suggest further cosmetic improvements that have not been covered by the consultation and leave the conversation open for the GDP to pick up.
Potential for excellent multidisciplinary approach if more than one therapist works alongside GDP
Treatment coordination and referral time reduced for GDP.
Realistically this may need a seismic shift in understanding within the dental team, but is an entirely possible model when working with well-trained and integrated team members.
“By adding the services of a full scope therapist to the dental practice, you free up time for the GDP to concentrate on the larger and more complex restorative cases.”
When you move toward a therapist led model you can start to really see a benefit in multidisciplinary working. If there are multiple therapists working alongside a GDP, in a close working relationship the therapist can take over the routine check-ups, allowing the GDP more time for case planning and high profit treatments. With more than one therapist working alongside a GDP the diaries can be arranged for the GDP to oversee treatment plans and pop in to the therapist check-ups in order to review and agree any complex treatment required. The model requires exceptional team working and communication but ultimately reduces lone working and gives patients a phenomenally efficient service. This model works best under the direct access arrangement.
Can be a good additional stream of revenue for hygienist/therapist diary
Excellent practice building potential.
There is also a softer way of integrating the therapist led model, by means of GDP initial consultations for new patients, and therapists undertaking the routine examinations thereafter. The GDP is still referred to for complex treatment planning, and makes themselves very visible during the therapist appointment in order to maintain the relationship with the patient and demonstrate a well-integrated and approachable team.
Post COVID-19 working
The future for dentistry in a post COVID-19 world is still very much unclear. However, with aerosol generating procedures being a huge source of concern, we may start to see better team integration than ever before. Dental surgeries may need to reorganise into aerosol generating rooms and non-aerosol rooms which could potentially open the door for therapists to take on far more of the workload than we have previously seen. Additionally the use of more protective PPE and the time constraints in using this and getting surgeries ready for the next treatment may mean that it is more cost effective to have two therapists treating to every GDP assessing and planning. There are likely to be changes in types of treatment that individuals are able to undertake dependent on the type of PPE available to them and so having a range of professionals available to undertake treatments will ease the logistical burden on practices.
There is an ingrained sense of uncertainty in some dental surgeries around utilising their hygienists' full skillset or the therapists' full scope. Often this is because the diary management hasn't changed for many years or the previous person in that role was not trained in additional skills later added to the scope of practice. Practices ought to take the lead from their hygienists and therapists, exploring together the ideal set up and ways to make that happen. The additional revenue, patient contact and patient care can be an invaluable addition to a successful business, and a happy team.